A woman develops atonic postpartum hemorrhage (PPH) after vaginal delivery that does not respond to initial medical management. What is the next best step in management in the labour room?
Q152
Which of the following is not used in the treatment of postpartum hemorrhage (PPH)?
Q153
A P1L1 lady after 4 hours of delivery is suffering from persistent, severe pain in the perineal region, rectal tenesmus, bearing down feeling and retention of urine. The probable diagnosis is :
Q154
Which of the following are correct regarding puerperal blues ?
I. Its incidence is around 50 %.
II. There is no specific metabolic or endocrine derangement.
III. Treatment is reassurance and psychological support.
Select the answer using the code given below :
Q155
Which of the following are correct in the treatment of cracked nipple?
I. Correct attachment (Latch on) will provide immediate relief from pain and rapid healing.
II. If pain, mother should use breast pump and the infant is fed with the expressed milk.
III. Antifungal medication (such as miconazole or nystatin) is applied to treat both the mother's nipple and the baby's mouth if there is oral thrush.
Select the answer using the code given below:
Q156
What are the causes of lactation failure after delivery ?
1. Infrequent suckling
2. Depression or anxiety state in the puerperium
3. Prolactin inhibition
Select the correct answer using the code given below :
Q157
Which of the following are correct regarding acute mastitis ?
1. It usually occurs in first 2 - 4 weeks postpartum.
2. Microscopic examination of breast milk shows leukocyte count more than 10^6/mL and bacterial count more than 10^3/mL.
3. Common organisms are bacteroids, E. coli and Klebsiella.
4. The source of infection is infant's nose and throat.
Select the correct answer using the code given below :
Q158
As per the definition of the World Health Organization, 'late maternal death' is defined as the death of a woman from direct or indirect obstetric causes, after more than X days but less than one year after termination of pregnancy. Which one among the following is the correct value of X?
Q159
A patient delivered a live healthy baby 4 hours back. Now she has developed persistent severe pain in the perineal region and rectal tenesmus. Local examination reveals a tense and tender purple swelling at the vulva. What is her probable diagnosis?
Q160
Following vaginal delivery, uterus becomes non-pregnant size by
Postpartum Care Indian Medical PG Practice Questions and MCQs
Question 151: A woman develops atonic postpartum hemorrhage (PPH) after vaginal delivery that does not respond to initial medical management. What is the next best step in management in the labour room?
A. Compression sutures
B. Immediate hysterectomy
C. Bakri balloon tamponade (Correct Answer)
D. Devascularization surgery
Explanation: ***Bakri balloon tamponade***
- This technique is considered the next step after failure of **initial medical management** (uterotonics) for **atonic PPH**, as it provides a minimally invasive way to achieve **intrauterine tamponade**.
- It can be rapidly inserted in the labour room, effectively bridging the time until other definitive surgical measures can be mobilized if needed.
*Compression sutures*
- These procedures (e.g., **B-Lynch suture**) are **surgical interventions** typically requiring laparotomy and are performed if non-surgical measures like balloon tamponade fail.
- They are considered a definitive surgical option, but usually, less invasive methods are attempted first when initial medical management is insufficient.
*Devascularization surgery*
- This entails procedures like uterine or internal iliac artery ligation, which are reserved for severe or refractory PPH when **uterotonics** and **tamponade balloons** have failed.
- These are advanced surgical steps that carry higher risks and are not the immediate next best step after failing initial medical measures.
*Immediate hysterectomy*
- This is the final, **life-saving measure** when all other conservative and surgical management options (medication, compression, tamponade, devascularization) have failed to control the hemorrhage.
- Since it results in loss of fertility and higher morbidity, it is always avoided unless absolutely necessary as a **last resort**.
Question 152: Which of the following is not used in the treatment of postpartum hemorrhage (PPH)?
A. Misoprostol
B. Carboprost
C. Dinoprostone (Correct Answer)
D. Oxytocin
Explanation: ***Dinoprostone***
- Dinoprostone is a prostaglandin E2 analogue primarily indicated for **cervical ripening** or **induction of labor**.
- It is not routinely used in the treatment of PPH because it is less effective than other uterotonics (like **Misoprostol** or **Carboprost**) for emergent control of uterine atony.
*Misoprostol*
- This is a synthetic **Prostaglandin E1 analogue** and an effective **uterotonic** agent used widely for PPH treatment, especially refractory cases or in low-resource settings.
- It is effective when administered by various routes (oral, sublingual, or **rectal**) and is beneficial due to its low cost and **heat stability**.
*Carboprost*
- Carboprost (15-methyl prostaglandin F2 $\alpha$) is a potent uterotonic agent reserved for treating PPH due to **uterine atony** when the first line (Oxytocin) has failed.
- It works by inducing intense **myometrial contractions**, but caution is needed as it is contraindicated in patients with active **asthma**.
*Oxytocin*
- This is the **most essential** and **first-line** uterotonic drug used for the prevention and treatment of **atonic postpartum hemorrhage**.
- It is usually administered intravenously as a bolus followed by an infusion, functioning by increasing the frequency and force of **uterine contractions**.
Question 153: A P1L1 lady after 4 hours of delivery is suffering from persistent, severe pain in the perineal region, rectal tenesmus, bearing down feeling and retention of urine. The probable diagnosis is :
A. Complete perineal tear
B. Cervical tear
C. Supralevator hematoma (Correct Answer)
D. Vulval hematoma
Explanation: ***Supralevator hematoma***
- A **supralevator hematoma** typically presents with severe, deep perineal or suprapubic pain, often accompanied by rectal tenesmus, a bearing-down sensation, and urinary retention due to mass effect and nerve compression.
- These hematomas are often **not visible externally**, as they are located above the levator ani muscle, making them difficult to diagnose without imaging or a high index of suspicion.
*Complete perineal tear*
- A **complete perineal tear** involves the anal sphincter and rectal mucosa, causing severe pain, but would typically present with visible disruption of the perineum and often fecal incontinence, rather than a deep, unobservable mass effect.
- While severe pain is present, the symptom complex of **rectal tenesmus, bearing down feeling, and urinary retention** in the absence of visible external trauma points away from a simple perineal tear.
*Cervical tear*
- A **cervical tear** would primarily cause significant **postpartum hemorrhage**, often with bright red blood, rather than the deep perineal pain, rectal tenesmus, and urinary retention described.
- While pain can occur, it's usually localized to the cervix or lower abdomen and not associated with a **bearing-down sensation** or difficulty voiding due to a mass.
*Vulval hematoma*
- A **vulval hematoma** causes severe pain and is usually **visible externally** as a tense, tender, and often discolored swelling of the labia.
- While it can cause urinary retention due to pressure on the urethra, the deep, severe pain and **rectal tenesmus** with a "bearing down" feeling, without visible external swelling, make a supralevator hematoma more likely.
Question 154: Which of the following are correct regarding puerperal blues ?
I. Its incidence is around 50 %.
II. There is no specific metabolic or endocrine derangement.
III. Treatment is reassurance and psychological support.
Select the answer using the code given below :
A. I, II and III (Correct Answer)
B. I and II only
C. II and III only
D. I and III only
Explanation: ***I, II and III***
- Puerperal blues, or **baby blues**, are very common, affecting around **50-80%** of new mothers within a few days postpartum.
- It is a transient condition thought to be related to **hormonal shifts** after childbirth, but without a specific, long-lasting metabolic or endocrine derangement requiring medical intervention. Its management involves **reassurance and psychological support**, as it typically resolves on its own without formal psychiatric treatment.
*I and II only*
- While statement I (incidence around 50%) is correct, and statement II (no specific metabolic or endocrine derangement) is also correct, this option excludes the crucial aspect of management, which is important for understanding the condition.
- The typical management of puerperal blues involves reassurance and support, making statement III integral to a complete understanding.
*II and III only*
- This option correctly identifies the lack of specific derangement and the treatment approach, but it underestimates the prevalence of puerperal blues.
- The incidence is significantly higher than implied by excluding statement I, making it a less accurate choice overall.
*I and III only*
- This option accurately describes the high incidence and the treatment strategy but overlooks the scientific understanding of its etiology.
- The lack of a specific metabolic or endocrine derangement (statement II) is a key characteristic differentiating it from more severe postpartum psychiatric conditions.
Question 155: Which of the following are correct in the treatment of cracked nipple?
I. Correct attachment (Latch on) will provide immediate relief from pain and rapid healing.
II. If pain, mother should use breast pump and the infant is fed with the expressed milk.
III. Antifungal medication (such as miconazole or nystatin) is applied to treat both the mother's nipple and the baby's mouth if there is oral thrush.
Select the answer using the code given below:
A. I, II and III (Correct Answer)
B. I and III only
C. II and III only
D. I and II only
Explanation: ***I, II and III***
- All three statements provide accurate and essential interventions for managing **cracked nipples** in breastfeeding mothers.
- **Correct latch-on** is fundamental to prevention and healing, expressing milk can provide relief and maintain supply, and **antifungal treatment** is indicated if candidiasis is suspected in both mother and infant.
*I and III only*
- This option incorrectly omits statement II, which describes a valid and often necessary intervention for managing pain and ensuring continued feeding.
- Using a **breast pump** allows the nipple to rest and heal while the infant still receives breast milk.
*II and III only*
- This option incorrectly omits statement I, which highlights the crucial role of **correct attachment (latch-on)** as the primary solution for preventing and healing cracked nipples.
- Without addressing the latch, other interventions may only provide temporary relief.
*I and II only*
- This option incorrectly omits statement III, which addresses the potential for **candidiasis (thrush)** as a cause of nipple pain and cracking.
- If thrush is present, antifungal treatment of both mother and baby is necessary for resolution.
Question 156: What are the causes of lactation failure after delivery ?
1. Infrequent suckling
2. Depression or anxiety state in the puerperium
3. Prolactin inhibition
Select the correct answer using the code given below :
A. 1 and 2 only
B. 2 and 3 only
C. 1 and 3 only
D. 1, 2 and 3 (Correct Answer)
Explanation: ***1, 2 and 3***
- **Infrequent suckling** directly reduces the stimulation needed for **prolactin release** and **milk production**, leading to lactation failure.
- **Depression or anxiety** can interfere with the **let-down reflex** by inhibiting **oxytocin release** and also decrease a mother's motivation and ability to breastfeed effectively.
- Any condition causing **prolactin inhibition**, such as certain medications (e.g., dopamine agonists) or specific medical conditions (e.g., Sheehan's syndrome), will directly prevent milk synthesis.
*1 and 2 only*
- This option correctly identifies infrequent suckling and emotional states as causes but fails to include **prolactin inhibition**, which is a direct and significant physiological factor in lactation failure.
- Excluding **prolactin inhibition** provides an incomplete understanding of all potential causes for inadequate milk production.
*2 and 3 only*
- This option correctly recognizes the impact of emotional states and prolactin inhibition but overlooks **infrequent suckling**, which is one of the most common behavioral reasons for reduced milk supply.
- Lack of adequate and frequent nipple stimulation is crucial for establishing and maintaining a robust milk supply.
*1 and 3 only*
- This option correctly identifies infrequent suckling and prolactin inhibition but omits the significant role of **maternal psychological states** like depression and anxiety in successful lactation.
- Emotional well-being heavily influences the **milk ejection reflex** and overall breastfeeding success.
Question 157: Which of the following are correct regarding acute mastitis ?
1. It usually occurs in first 2 - 4 weeks postpartum.
2. Microscopic examination of breast milk shows leukocyte count more than 10^6/mL and bacterial count more than 10^3/mL.
3. Common organisms are bacteroids, E. coli and Klebsiella.
4. The source of infection is infant's nose and throat.
Select the correct answer using the code given below :
A. 1, 3 and 4
B. 1, 2 and 3
C. 1, 2 and 4 (Correct Answer)
D. 2, 3 and 4
Explanation: ***1, 2 and 4***
- **Acute mastitis** most frequently occurs within the **first 2-4 weeks postpartum** during lactation establishment (Statement 1 correct)
- Diagnosis of infectious mastitis is confirmed by **breast milk culture** showing **leukocyte count > 10^6/mL** and **bacterial count > 10^3/mL** (Statement 2 correct)
- **The primary source of infection** is the infant's **nose and throat flora**, which colonizes the mother's nipple and invades through cracks or fissures (Statement 4 correct)
- **Staphylococcus aureus** is the most common causative organism, not Bacteroides, E. coli, or Klebsiella (Statement 3 incorrect)
*1, 3 and 4*
- While statements 1 and 4 are correct, statement 3 incorrectly identifies the common organisms
- The primary organism responsible for acute mastitis is **Staphylococcus aureus** from infant's oral flora, not anaerobes or gram-negative organisms
*1, 2 and 3*
- Statements 1 and 2 are correct, but statement 3 is incorrect
- **Staphylococcus aureus** accounts for the vast majority of mastitis cases, not Bacteroides, E. coli, or Klebsiella
*2, 3 and 4*
- Statements 2 and 4 are correct, but statement 3 incorrectly identifies the causative organisms
- The correct organism is **Staphylococcus aureus**, not the organisms listed in statement 3
Question 158: As per the definition of the World Health Organization, 'late maternal death' is defined as the death of a woman from direct or indirect obstetric causes, after more than X days but less than one year after termination of pregnancy. Which one among the following is the correct value of X?
A. 21
B. 7
C. 84
D. 42 (Correct Answer)
Explanation: ***Correct: 42***
- According to the **World Health Organization (WHO)**, **late maternal death** is defined as the death of a woman from direct or indirect obstetric causes occurring **more than 42 days** but less than one year after termination of pregnancy.
- This definition helps in categorizing and understanding the timeframe and causes of maternal mortality beyond the immediate postpartum period.
- The **42-day threshold** distinguishes between direct maternal deaths (within 42 days) and late maternal deaths (42 days to 1 year).
*Incorrect: 21*
- This value is not used in the WHO definition for the onset of late maternal death.
- The **42-day mark** is the internationally recognized threshold for distinguishing between the immediate postpartum period and late maternal complications.
*Incorrect: 7*
- Seven days is too short a period for a death to be classified as **"late maternal death"**; deaths within this timeframe fall under **direct maternal deaths** in the immediate postpartum period.
- This period is often associated with immediate postpartum complications such as **postpartum hemorrhage**, **eclampsia**, or **early-onset puerperal sepsis**.
*Incorrect: 84*
- While 84 days (12 weeks) is a significant period in postpartum recovery for some physiological changes, it is not the specific threshold used by the **WHO** to define the beginning of **late maternal death**.
- The international standard remains **42 days** (6 weeks) as the transition point between direct and late maternal deaths.
Question 159: A patient delivered a live healthy baby 4 hours back. Now she has developed persistent severe pain in the perineal region and rectal tenesmus. Local examination reveals a tense and tender purple swelling at the vulva. What is her probable diagnosis?
A. Ruptured uterus
B. Vulvar hematoma (Correct Answer)
C. Cervical tear
D. Perineal tear
Explanation: ***Vulvar hematoma***
- A **vulvar hematoma** presents with severe, persistent perineal pain and a tense, tender, purple swelling at the vulva, often accompanied by **rectal tenesmus** due to pressure from the expanding hematoma.
- This condition typically occurs after childbirth due to **trauma to blood vessels** during delivery, where blood accumulates in the vulvar tissues, forming a palpable mass.
- Vulvar hematomas are a type of puerperal hematoma that occur in the superficial tissues and are visible on examination.
*Ruptured uterus*
- A **ruptured uterus** is an obstetric emergency characterized by sudden, severe abdominal pain, vaginal bleeding, and signs of **fetal distress** or **maternal shock**.
- It usually occurs during labor or delivery and is not associated with localized perineal swelling or rectal tenesmus as the primary presentation.
*Cervical tear*
- A **cervical tear** typically causes persistent, bright red vaginal bleeding after delivery, but the uterus is usually well-contracted.
- While it can cause pain, it does not present with a palpable, tense, purple swelling at the vulva or rectal tenesmus.
*Perineal tear*
- A **perineal tear** causes pain and can be associated with swelling, but it usually presents as a visible laceration or superficial injury.
- While it can cause pain and some swelling, it does not typically manifest as a tense, discrete purple mass with pronounced rectal tenesmus unless complicated by hematoma formation.
Question 160: Following vaginal delivery, uterus becomes non-pregnant size by
A. 9 weeks postpartum
B. 8 weeks postpartum
C. 6 weeks postpartum (Correct Answer)
D. 4 weeks postpartum
Explanation: ***6 weeks postpartum***
- This period allows for sufficient **myometrial contraction** and involution to return the uterus to its pre-pregnancy size through the process of **autolysis** and fundal descent.
- The uterine weight decreases significantly from about 1000g immediately after delivery to approximately 50-70g by 6 weeks.
- By the end of the puerperium (6 weeks), complete uterine involution is achieved.
*9 weeks postpartum*
- By 9 weeks, uterine involution would have been completed much earlier, and the uterus would have attained its **non-pregnant size** several weeks prior.
- This timeframe is typically beyond the normal window for the completion of uterine regression.
*8 weeks postpartum*
- Similar to 9 weeks, by 8 weeks postpartum, the uterus would have already returned to its **non-pregnant state**.
- The process of **involution** is usually completed well before this mark.
*4 weeks postpartum*
- While significant **uterine involution** occurs by 4 weeks, the uterus may still be slightly larger and heavier than its pre-pregnancy size.
- Complete return to the **non-pregnant state** typically requires an additional two weeks.
